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Ten Things to Know About Ten Imaging Studies: a Preventive Cardiology Perspective ( “ASPC Top Ten Imaging ”)

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Ten Things to Know About Ten Imaging Studies: a Preventive Cardiology Perspective ( “ASPC Top Ten Imaging ”) American Journal of Preventive Cardiology 6 (2021) 100176 Contents lists available at ScienceDirect American Journal of Preventive Cardiology journal homepage: www.journals.elsevier.com/the-american-journal-of-preventive-cardiology State-of-the-Art Review Ten things to know about ten imaging studies: A preventive cardiology perspective ( “ASPC top ten imaging ”) Harold E. Bays a,∗, Amit Khera b, Michael J. Blaha c, Matthew J Budoff d, Peter P. Toth e,f a Louisville Metabolic and Atherosclerosis Research Center, 3288 Illinois Avenue, Louisville KY 40213 USA b UT Southwestern Medical Center, Dallas, TX USA c Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore MD USA d Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance CA USA e CGH Medical Cener, Sterling, IL 61081 USA f Cicarrone center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD USA a r t i c l e i n f o a b s t r a c t Keywords: Knowing the patient’s current cardiovascular disease (CVD) status, as well as the patient’s current and future CVD Coronary artery calcium imaging (CAC) risk, helps the clinician make more informed patient-centered management recommendations towards the goal Coronary computed tomography angiography of preventing future CVD events. Imaging tests that can assist the clinician with the diagnosis and prognosis of (CCTA) CVD include imaging studies of the heart and vascular system, as well as imaging studies of other body organs ap- Cardiac ultrasound plicable to CVD risk. The American Society for Preventive Cardiology (ASPC) has published “Ten Things to Know Echocardiography Nuclear myocardial perfusion imaging (MPI) About Ten Cardiovascular Disease Risk Factors.” Similarly, this “ASPC Top Ten Imaging” summarizes ten things Cardiac magnetic resonance (CMR) to know about ten imaging studies related to assessing CVD and CVD risk, listed in tabular form. The ten imaging Cardiac catheterization studies herein include: (1) coronary artery calcium imaging (CAC), (2) coronary computed tomography angiog- Intravascular ultrasound (IVUS) raphy (CCTA), (3) cardiac ultrasound (echocardiography), (4) nuclear myocardial perfusion imaging (MPI), (5) Coronary optical coherence tomography (OCT) cardiac magnetic resonance (CMR), (6) cardiac catheterization [with or without intravascular ultrasound (IVUS) or coronary optical coherence tomography (OCT)], (7) dual x-ray absorptiometry (DXA) body composition, (8) hepatic imaging [ultrasound of liver, vibration-controlled transient elastography (VCTE), CT, MRI proton den- sity fat fraction (PDFF), magnetic resonance spectroscopy (MRS)], (9) peripheral artery / endothelial function imaging (e.g., carotid ultrasound, peripheral doppler imaging, ultrasound flow-mediated dilation, other tests of endothelial function and peripheral vascular imaging) and (10) images of other body organs applicable to preventive cardiology (brain, kidney, ovary). Many cardiologists perform cardiovascular-related imaging. Many non-cardiologists perform applicable non-cardiovascular imaging. Cardiologists and non-cardiologists alike may benefit from a working knowledge of imaging studies applicable to the diagnosis and prognosis of CVD and CVD risk – both important in preventive cardiology. What is already known about this subject? What are the new findings in this manuscript? • The American Society for Preventive Cardiology (ASPC) has pub- • The “ASPC Top Ten Imaging ” summarizes ten things to know about lished “Ten Things to Know About Ten Cardiovascular Disease (CVD) ten important CVD-related imaging studies (listed in a tabular for- Risk Factors, ”[ 1 , 2 ] which summarizes major CVD risk factors, ac- mat). companied by sentinel reviews or guidelines relative to ten impor- • Non-cardiologists (e.g., primary care physicians, nurse practition- tant CVD risk factors. ers, physician assistants, gynecologists, endocrinologists, obesity • Assessing existing CVD and CVD risk through imaging is commonly medicine specialists, lipidologists, diabetologists etc.) may benefit used to stratify CVD risk and influence CVD prevention management. from an overview of CVD-related imaging studies commonly per- Diagnostic and prognostic imaging studies of the heart and other formed by cardiologists. Cardiologists may benefit from an overview body organs help clinicians with management decisions to prevent of imaging studies beyond the heart, but applicable to global pre- future CVD events. ventive cardiology –which are imaging studies often performed by non-cardiologists. ∗ Corresponding author. E-mail addresses: [email protected] (H.E. Bays), [email protected] (A. Khera), [email protected] (M.J. Blaha), mbudoff@lundquist.org (M.J. Budoff), [email protected] (P.P. Toth). https://doi.org/10.1016/j.ajpc.2021.100176 Received 1 December 2020; Received in revised form 16 March 2021; Accepted 19 March 2021 2666-6677/© 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) H.E. Bays, A. Khera, M.J. Blaha et al. American Journal of Preventive Cardiology 6 (2021) 100176 • In addition to the “Top Ten ” things to know about CVD imaging stud- 3. Appropriate use [ 4 , 5 ] ies, citations are listed in the applicable tables to provide the reader more in-depth resources (e.g., illustrative guidelines and other ref- • The choice of cardiac imaging studies should be based upon estab- erences) pertaining to each imaging category. lished “Appropriate Use ” criteria, [ 4 , 5 ] and individual patient pre- sentation. • Appropriate imaging studies are those where the clinical benefits and value in an individual patient exceed the risk ( Reference Chart 1 ) 1. Introduction and cost, through providing clinically meaningful information about CVD and CVD risk, beyond clinical judgment alone. The intent of the “American Society for Preventive Cardiology • Appropriate use of imaging studies includes procedures most likely (ASPC) Top Ten Imaging ”is to help primary care clinicians and car- to provide safe and definitive answers to the diagnostic questions diology specialists keep up with the ever-increasing pace of diagnos- raised, and least likely to prompt further imaging studies and in- tic and prognostic imaging studies applicable to preventive cardiol- vasive downstream procedures, irrespective of the initial imaging ogy. Imaging studies focused on the heart are often performed by study results. In other words, in the interest of limiting the risks and cardiologists and/or radiologists and help with diagnosis and progno- costs of multiple imaging procedures, the choice of cardiac imaging sis. Other imaging studies may also help in CVD risk stratification, procedure should focus on which procedure is likely to provide the and include imaging studies of the peripheral vasculature, body fat, greatest amount of actionable information applicable to the individ- liver, brain, kidney, and ovary. The “ASPC Top Ten Imaging ” sum- ual patient, in the safest manner possible. marizes ten things to know about ten CVD-related imaging studies, • Clinicians should be cautious and judicious in cardiac imaging stud- listed in tabular formats. These ten imaging studies include: (1) coro- ies in patients at low CVD risk, especially for imaging studies that nary artery calcium (CAC) imaging and scoring, (2) coronary computed have low specificity in patients at low CVD risk. Low specificity car- tomography angiography (CCTA), (3) cardiac ultrasound (echocardio- diac imaging in low CVD risk patients may often lead to false positive graphy), (4) nuclear myocardial perfusion imaging (MPI), (5) cardiac results. False positive findings on cardiac imaging may needlessly magnetic resonance (CMR), (6) cardiac catheterization [with or with- prompt more invasive, more costly, and potentially unnecessary ad- out intravascular ultrasound (IVUS) or coronary optical coherence to- ditional testing and/or procedures, resulting in more health risk than mography (OCT)], (7) dual x-ray absorptiometry (DXA) body composi- benefit. tion, (8) hepatic imaging [ultrasound of liver, vibration-controlled tran- • Selecting the most appropriate imaging test should take into con- sient elastography (VCTE), CT, MRI proton density fat fraction (PDFF), sideration whether the patient is symptomatic or asymptomatic. magnetic resonance spectroscopy (MRS)], (9) peripheral artery / en- Performing cardiac imaging studies with low selectivity in asymp- dothelial function imaging (e.g., carotid ultrasound, peripheral doppler tomatic patients at low CVD risk has a higher risk of false positive imaging, ultrasound flow-mediated dilation, other tests of endothelial findings than cardiac imaging studies with high selectivity in symp- function and peripheral vascular imaging) and (10) images of other tomatic patients at high CVD risk ( Reference Chart 2 ). body organs applicable to preventive cardiology (brain, kidney, ovary). • Procedures having the most robust evidence to support use in screen- ( Fig. 1 ) ing for coronary artery disease in asymptomatic individuals include The intent is not to create a comprehensive discussion of all imaging family history assessment for premature CVD, CVD risk factor as- studies applicable to CVD assessment. Nor is this document intended to sessment, and CVD and CHD risk scores. [ 1 , 24 ] Additional diagnos- be a comprehensive discussion of each imaging study. Rather, the intent tic procedures having evidenced-based
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